Peace Love and Poms Rescue

First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
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County*

Country*

Email*

Home Phone*

Cell Phone*

Alt Email

What is the name(s) of the dog(s) you wish to surrender?*

How old is the dog(s)?*

How much does the dog(s) weigh?*

What breed or mix is the dog?*

What is the reason for surrendering your dog(s)*

How long have you owned the dog and where did you get the pet?*

Is the dog spayed or neutered*
Choose one: Yes No

Is the dog up to date on vaccines (Rabies, Parvo/Distemper)?*
Choose one: Yes No

Has the dog had dental cleanings or tooth extractions done by a vet?*
Choose one: Yes No

Are there any medical issues we should know about? (please be truthful as withholding information can cause serious harm or death to a dog, and we do not base intakes on medical issues)*

Does your dog have any behavior issues? These could be small things like marking in the home, or major things like a history of biting. Please disclose all known behavior issues so dogs can be appropriately accommodated by foster homes.*

Is the dog housetrained or pee pad trained?*
Choose one: Yes No

Does the dog walk well on a leash?*
Choose one: Yes No

Is the dog crate trained?*
Choose one: Yes No

Is your dog currently taking flea and tick preventatives?*
Choose one: Yes No

Has your dog been tested for heart worms? Is the dog now or ever heart worm positive?*

Is your dog good in a car? If not, please explain.*

Does your dog do well with other dogs? Cats?*

Is your dog good with people? How do they act with strangers or going to the vet and groomer?*

Does your dog have any history of aggression or bites? If yes, please explain. (Please be truthful as we do rehabilitate behavior cases when we have the space, and must know of any bite history due to liability on our organization)*

Does your dog have any anxiety whether general or in certain situations? *

What does your dog currently eat?*

Is there anything additional you would like to add to help us find an appropriate foster home for your dog? *